by Allan Schwartz, DDS, CRNA - Sedation Consult€¦ · by Allan Schwartz, DDS, CRNA This print or...

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AUGUST 2014 » dentaltown.com74


by Allan Schwartz, DDS, CRNA

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AbstractThis article covers a few of the most common

emergency medications found in many proprietary dental emergency medication kits. Every dentist should periodically review the uses and be familiar with these medications and share this information with their staff.

Educational ObjectivesAt the end of this program the participant will

be able to:1. Describe the immediate use of oxygen in a

dental emergency.2. Discuss the physiological function of oxygen.3. Discuss the meaning of Fraction of inspired

oxygen (FIO2).

4. Discuss the oxygen delivery of various airway devices.

5. Describe the consistency of inhaled spirits of ammonia and its use in hypotension.

Patients, family, employees and even the dentist could have a situation progress to an emergency. With

proper preparation, training and periodic practice drills, the dental office can help stabilize the patient until emergency response personnel arrive. The office will also remain compliant with various state dental board requirements for medical emergency office pre-paredness. The dentist is responsible for knowing the particular state board dental rules and laws that gov-ern his or her permission to practice dentistry.

The public should know that dentists are con-cerned with more than just the well-being of their teeth, face, neck and mouth. We are concerned with the patient’s overall body and health. The American Dental Association Council on Scientific Affairs states, “dentists must be prepared to recognize and properly manage patients who are experiencing medi-cal emergencies in the dental office.” Therefore, emer-gency preparedness and knowledge are essential, and should be an ongoing endeavor in the dental office.

This course should also encourage dentists and their auxiliary personnel to read, attend courses and study further to learn ways to provide more com-plete service to our patients.



continued from page 75

Approximate FIO

2 of Oxygen

Administration Devices

30% Nasal Cannula at 3L/minute flow

30-40% Nasal Hood at 3L/minute flow

50% Simple oxygen face mask at 6L/minute flow

80-100% Non-rebreathing face mask at 6L/minute flow

100% Bag-Mask-Valve at 8L/minute flow

100% Endotracheal tube; Laryngeal Mask Airway (LMA); king airway

1FIG

Oxygen

Many dentists do not think of oxygen as an emergency drug, but indeed it is. Oxygen has pharmacokinetic and pharmacodynamic properties like other inhaled anesthetic agent we use. Oxygen should be one of the first emergency medications you automatically think of, especially since an emergency situation is already stress-ful enough!

Every major organ (heart, lungs, liver, kidneys, brain) as well as every cell of the body depends on a constant supply of oxygen for metabolism within its cells. Oxygen is necessary for the chemical reactions that occur within cellular mitochondria. Mi-tochondria create the molecule adenosine triphosphate, which provides high-energy phosphate molecules as fuel for our cell’s metabolic function.

Oxygen and breathing can start you thinking in an already stressful, urgent or emergent situation. Oxygen administration starts you thinking of C, A, B, D (cir-culation, airway, breathing, defibrillation/diagnosis) which you learned in basic life support (BLS) for health-care workers, or ACLS training. Oxygen is extremely easy to administer, is readily available and is rapidly effective.

Air contains a mixture of gases, the majority of which are: nitrogen, oxygen, carbon dioxide and water vapor. The amount of oxygen a patient breathes is called the fraction of inspired oxygen or FiO

2. FiO

2 is expressed as a percentage of the total

mixture of all of the gases the patient is breathing. Your own FiO2, as you are breath-

ing room air right now, is about 21 percent. Patients can receive differing concen-trations of oxygen (FIO

2) depending on the various devices available to administer

oxygen to patients (see Fig. 1).The bottom line is to administer oxygen to the patient experiencing an emergen-

cy with a device that provides the highest FIO2 as quickly as possible to provide an

oxygen-rich gas mixture that will circulate to all of their body’s cells, especially to the vital organs.




Albuterol

In order to understand the pharmacology of the inhaled emergency med-ication albuterol, a review of the adrenergic receptors is in order. Adrenergic receptors are found along blood vessels, especially arterioles, lung tissues, the heart, our eyes, our gastrointestinal tract, and many other tissues. Adrener-gic receptor agonists are epinephrine, norepinephrine and some intravenous anesthesia medications such as phenylephrine and ephedrine.

There are three adrenergic receptor types, which we are especially con-cerned about in emergency dental situations: alpha 1, alpha 2, and beta 1. Figure 2 summarizes the actions of adrenergic receptor stimulation of tissues.

You administer inhaled albuterol puffs in order to stimulate beta 2 recep-tors. Beta 2 stimulation produces bronchodilation of lung tissues in a patient who may be asthmatic or short of breath. In order for the albuterol vapor to contact the bronchiolar smooth muscle and relax the muscle, help the patient administer the albuterol the proper way with these instructions:

1. Begin by having the patient exhale as deeply as possible.2. Administer a puff of the albuterol and inhale deeply.3. Hold the breath as long as comfortably possible, allowing the albuter-

ol to contact the surface of the bronchi and the alveoli.4. Exhale and then auscultate the lungs with a good stethoscope.5. Repeat steps 1 to 4 as necessary.

The Actions of Adrenergic Stimulation on Tissues

alpha 1 stimulation: vasoconstriction of arterioles and arteries beta 1 stimulation: increases heart rate beta 2 stimulation: causes bronchodilation of the bronchioles of the lungs

2FIG

“In order for the albuterol vapor to contact the bronchiolar

smooth muscle and relax the muscle, help the patient

administer the albuterol the proper way”

References:1. Grogan D.M. The pharmacology of recommended medical emergency drugs.

Texas Dental Journal. December 2004. Pp. 1140-1148.2. Field J.M. ACLS Provider Manual. American Heart Association. 2006, pp.7-10.3. Office emergencies and emergency kits. ADA Council on Scientific Affairs.

JADA, Vol. 133, March 2002, pp. 364-365.4. Guyton A. Hall J. Textbook of Medical Physiology. Eleventh edition. Philadel-

phia. Elsevier. 2006, pp. 493,732-753, 833-8355. Requa-Clark B. Applied Pharmacology for the Dental Hygienist. Fourth

Edition. St. Louis. Mosby. 2000. pp. 91-1006. Dubin D. Rapid Interpretation of EKG’s. Sixth Edition. Tampa. Cover

Publishing Company. 2000, p.68.7. Nagelhout J. Zaglaniczny K. Nurse Anesthesia. Third Edition St. Louis.

Elsevier Saunders. 2005, p. 199.8. Malamed SF. Medical Emergencies in the Dental Office. St. Louis. Mosby-El-

sevier. 2000,p. 81.

9. Omoigui S. The Anesthesia Drugs Handbook. Second Edition. St. Louis. Mosby-Yearbook.1995.

10. Stoelting R. Pharmacology and Physiology in Anesthetic Practice. Fourth Edition. Philadelphia. Lippincott, Williams, and Wilkins. 2006. Pp.

11. Zaglaniczny, K. Aker J. Clinical Guide to Pediatric Anesthesia. Philadelphia. W.B. Saunders, Co. 1999.

12. Hurford W.E. Clinical Anesthesia Procedures of the Massachusetts General Hospital. Fifth Edition. Philadelphia. Lippincott-Raven. 1998.

13. Dingwerth D.J. Office emergency preparation and equipment. Texas Dental Journal. December 2004. Pp. 1132-1138.

14. Mosby’s Nursing Drug Reference, 2011. St. Louis. Mosby Elsevier. 2011.15. Donnelly AJ, Baughman VL, Gonzales JP. Anesthesiology & Critical Care

Drug Handbook. Hudson, Ohio. Lexicomp. 2008. 16. www.ismp.org/tools/tallmanletters.pdf17. http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?-

StandardsFaqId=143&ProgramId=1

Inhaled spirits of ammonia (smelling salts) consists of a 0.3ml friable glass ampule filled with liquid ammonia and isopropyl alcohol, surrounded by a heavy paper or cloth, which prevents skin contact with the shards of the broken glass ampule.

If a patient experiences lightheadedness, has become over-sedated, or develops hypotension (syncope, fainting), the dentist snaps or crushes the glass ampule and holds the exposed ammonia vapors in front of the nose of the patient. The pungent and irritating ammonia vapors serve to stimulate the patient’s sensorium and should awaken the patient.

Inhaled spirits of ammonia is an “old fashioned” remedy for syncope. It irritates the nasal and esophageal mucosa, causing excess muscous production. Inhaled ammonia also irritates the fundus of the stomach, causing the excess production of stomach acid.

Athough there are other substitutes for inhaled spirits of ammonia, some dental boards specifically require the dentist to stock ammonia ampules and have them readily and quickly available. Consult with your state’s dental board rules. You are responsible for reading and knowing the rules that govern your dental practice.

We discussed the use of oxygen as a first-line drug to supply necessary oxygen to the vital organs and tissue of the body. Adrenergic receptors are stimulated to cause an increase in blood pressure, an increase in heart rate, and bronchodilation by albuterol. Finally, inhaled spirits of ammonia although old-fashioned, stimulate arousal of patients experiencing hypotension, syncope or oversedation. n

Inhaled Spirits of Ammonia

Author’s Bio

Dr. Schwartz is a 1980 graduate of Baylor College of Dentistry in Dallas, Texas. He attended a general practice residency in general dentistry from the Jewish Hospital of St. Louis, Missouri from 1980 to 1981. In 1990, he attained his Bachelor of Science in Nursing Degree from St. Louis University, and in 1994 he graduated from Washington University School of Nurse Anesthesia in Saint Louis.

He has practiced as a Certified Registered Nurse Anesthetist since 1994, and practices dentistry with interest in anesthesia at dental practices in Missouri, delivering anesthetic care to patients as a licensed dentist with a certificate issued by the Missouri Dental Board in deep sedation/general anesthesia.

He is the author of several anesthesia and nursing journal articles, and the author of chapters in four nurse anesthesia textbooks. Also check out the website SedationConsult.com for live courses such as ACLS for Dentists, a course created just for dentists and their staff, and The Essentials of Monitoring of the Sedated Dental Patient.

Disclaimer: The intent of this presentation is to familiarize dentists with some of the more common dental office emergencies, medications you may use in the event of an office emergency, the basic physiological basis for the emergency, and the rationale for the use of these medications. No specific outcomes, warranties, or guarantees are expressed or implied for your patients with the drugs and dosages discussed.

You are referred to a recognized pharmacology textbook, anesthesia textbook, pharmacist, or drug handbook for the manufacturer’s specific recommendations pertaining to the medications discussed.






1. Oxygen is used by which organelle to manufacture ATP for the cell?

a. Golgi apparatus

b. Nucleus

c. Mitochondria

d. Endoplasmic reticulum

2. Which airway device delivers the highest FIO2 to the patient?

a. Nasal hood

b. Nasal cannula

c. Simple face mask

d. Non-rebreathing face mask

3. Your state dental board can dictate the emergency medications you

must carry and your familiarity with these medications.

a. True

b. False

4. Which gas is not a constituent of room air?

a. Chlorine

b. Oxygen

c. Nitrogen

d. Water Vapor

5. Albuterol primarily stimulates which receptor?

a. Alpha 1

b. Alpha 2

c. Beta 2

d. Beta 1

6. Albuterol causes bronchoconstriction of the lung passages.

a. True

b. False

7. Which is a natural adrenergic agonist?

a. Serotonin

b. Norepinephrine

c. Acetylcholine

d. Dopamine

8. Which of the following is not one of the steps in administering

oxygen?

a. Circulation

b. Airway

c. Breathing

d. Glucose Level

9. Inhaled Spirits of Ammonia is used to treat:

a. Hypoglycemia

b. Hypertension

c. Allergy

d. Angina Pectoris

e. Hypotension

10. Inhaled Spirits of Ammonia does not cause:

a. Hyperglycemia

b. Stomach acid secretion

c. Excess mucous

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Three Basic Emergency Medications You Should Know How to Use by Allan Schwartz, DDS, CRNA

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